Dissatisfaction of people with type 2 diabetes with the care received at a diabetes clinic in Ningbo, China: A cross‐sectional study

Abstract Aim The study aimed to assess the dissatisfaction of people with type 2 diabetes mellitus (T2DM) with the care that they received at a diabetes outpatient clinic in Ningbo, China and to determine the associated factors. Methods A cross‐sectional study was conducted among 406 adults with T2DM in 2020–2021. Those who were treated at the diabetes outpatient clinic for at least six consecutive months before the survey date were eligible. The Short Assessment of Patient Satisfaction scale was used to assess participants' dissatisfaction with the care that they received. Results Of the participants, 25.1% were not satisfied with the care that they received at the diabetes outpatient clinic in Ningbo. The odds of dissatisfaction were higher in physically active people compared to those who were not (odds ratio [OR]: 3.41; 95% confidence interval [CI]: 1.56–7.45) and those with >1–5 years of T2DM compared to ≤1 year (OR: 2.18; 95% CI: 1.05–4.53). Conclusion A quarter of people with T2DM were dissatisfied with the care that they received at the diabetes outpatient clinic in Ningbo, China, and the factors associated with dissatisfaction were identified.

and economic consequences are major concerns in China. 5,6 Ningbo, located in the northeast of China, is one of the most economically developed cities, and around 21% of people over 40 years of age have T2DM. 7 In China, there is no referral system and people are allowed to attend any hospital and clinic of their choice. 8 No permanent cure exists for T2DM, and high-quality care should be provided to people with T2DM throughout their lifespan. 9 This high-quality care should be comprehensive and include routine check-ups to enforce lifestyle modification, prescribe and adjust medication, and detect and manage any T2DM-related complications and comorbidities. 10 Patients' views, such as satisfaction with the treatment provided, explanation of treatment results, clinician care, participation in medical decision-making, respect by the clinician, time with the clinician, and satisfaction with the hospital or clinic care, are important. 11 The dissatisfaction of people with T2DM with the care that they received can have a major negative impact, such as poor self-efficacy and nonadherence to therapy and ultimately leading to poorer outcomes like poor glycemic control and T2DM complications. 12 Thus, there is a need to explore dissatisfaction in patients and address their concerns as part of health service improvement. 11 However, limited research has been conducted on this issue in other parts of China. 13,14 Therefore, the study aimed to assess the dissatisfaction of people with T2DM with the care that they received at a diabetes outpatient clinic in Ningbo, China and to determine the associated factors.

| Study participants and eligibility criteria
The study included people with T2DM, aged 18 years or above. The T2DM diagnosis was based on the Chinese guideline. 15 People who were treated at the diabetes outpatient clinic for at least six consecutive months before the survey date and gave written informed consent to participate in the study were included. T2DM being a chronic disease, six months' time is useful to adjust to the treatment and reflect on the care received. 8

| Data collection tool and procedure
A quantitative questionnaire in Mandarin was used for data collection. The self-reported nonstandardized questions were developed and pretested in six people with T2DM (not included in this study). Five trained nurses collected and entered the data. A doctor was responsible for checking the data quality. Data on the following variables were collected (and categorized): age (18-39, 40-59, or ≥60 years), sex (male or female), education (university/college, class 7-12, class 1-6, or no qualification), occupation (manual worker, nonmanual worker, or retired/never worked), marital status (married or single/divorced/widowed), residence (urban or rural; based on the "hukou" residence registration system in China 16  Assessment of Patient Satisfaction scale was used to assess participants' dissatisfaction with the care that they received. 11 It is a seven-item scale that focuses on treatment satisfaction, explanation of treatment results, clinician care, participation in medical decision-making, respect by the clinician, time with the clinician, and satisfaction with clinic care. The total score starts from 0 (very dissatisfied) to 28 (very satisfied). For this study, very dissatisfied (0-10) and dissatisfied (11)(12)(13)(14)(15)(16)(17)(18) were combined as dissatisfied.

| Sample size
At least 377 participants were required in the study based on a 95% confidence level (CI) and a 5% margin of error. 22 Consecutive people with T2DM were approached and recruited 406 participants.

| Ethics approval
Ethics approval was received from the Research Ethics Committee of Ningbo First Hospital. The participant information sheet and consent form were available in Mandarin. The study objective was explained to all the eligible participants, and written informed consent was taken from those interested in participating.

| Statistical analyses
We calculated the number and percentage for categorical variables and mean and standard deviation (SD) for normally distributed continuous data. A χ 2 test was conducted, and the result was considered statistically significant when the p value was ≤0.05.
We developed a multiple logistic regression model to determine the factors independently associated with dissatisfaction, and for this, we

| RESULTS
Participant characteristics are reported in Table 1. The mean age of participants was 56.3 years (SD ± 12.6), and 62.6% were men. Of the participants, 25.1% were not satisfied with the care that they received at the diabetes outpatient clinic in Ningbo, China, and physically active (p = 0.003) and duration of T2DM (p = 0.037) were found to be associated with it. Table 2 shows the multiple logistic regression analysis to determine the factors independently associated with dissatisfaction.
The odds of dissatisfaction were higher in physically active people compared to those who were not (OR: 3.41; 95% CI: 1.56-7.45) and those with >1-5 years of T2DM compared to ≤1 year (OR: 2.18; 95% CI: 1.05-4.53). Similar results were found in the sensitivity analysis.

| DISCUSSION
Around 25% of participants in this study were not satisfied with the care that they received at the diabetes outpatient clinic in Ningbo, China. This is consistent with the worldwide literature on patient satisfaction, including people with T2DM, which shows that around 10%-30% of patients are dissatisfied with their health care. 11,[23][24][25] Studies conducted in other parts of China among people with T2DM found moderate levels of satisfaction (mean scores: 3.14 out of 5 and 34.54 out of 60). 13,14 A direct comparison between the findings should be avoided as different questionnaires were used in the studies-one had a short question on satisfaction and the other used a different standardized questionnaire. 13 writingreview and editing.

ACKNOWLEDGMENTS
The authors thank the study participants. The study was funded by the Nottingham China Health Institute, China. The funding agency had no role in designing the study or in writing the manuscript.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data set will be available upon request unless there are legal or ethical reasons for not doing so.

TRANSPARENCY STATEMENT
The lead author Kaushik Chattopadhyay affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.